computerized medical records are efficient

There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages. The first is efficiency.

The enormous amount of data that are collected about a person’s health can be stored and organized in a more efficient method than our current paper system permits. It is time consuming to find data in a patient’s chart. The larger the chart becomes, the less easy it is to use it to locate key information.

An electronic medical record can be searched to find key pieces of information. The ability of electronic health records to compress large amounts of data into minimal space relieves providers of the pressure to cull files.

Placement of bar codes on medical record forms permits a handwritten form to be scanned and saved in the correct section of an electronic chart.

Being able to use standardized order sets saves the prescriber time. For example, certain patients with specific diagnoses may need the same laboratory work ordered every time a treatment regimen begins. The ability of prescribers to access the order sets, without having to remember what they are, facilitates care.

The electronic medical record could lead to a more efficient transfer of information from one healthcare provider to another.

When using manual methods of documentation, duplication of testing and data collection can occur during care transfer from one provider to another. Cost containment and healthcare reform mandate improving efficiency in the management of healthcare data.

An electronic record may be simultaneously viewed by more than one person.

The electronic medical record can be accessed by authorized people located at a remote site. For example, the physician managing the care of a nursing home resident or hospital patient can access laboratory results, orders, and medical and nursing documentation in order to make clinical decisions.

Computerized documentation supports economical use of the data entry process by reducing or eliminating redundant charting.

A one-time entry of a piece of information into the program can be sent to all of the appropriate places. For example, the patient’s allergy to Morphine should show up wherever this information is needed, such as in the pharmacy, on the medication administration record, and as an alert in the clinical information system.

Copying of medical records prior to transferring a patient to a different facility can be eliminated under the electronic health record model. This system would permit the receiving facility’s providers to be able to access the information gathered at the sending facility.

Hospital bedside monitors, laboratory equipment, and other devices provide data which may be electronically incorporated into the patient’s medical record.

The ability to review records of prior hospitalizations permits the healthcare team to obtain data about prior medical problems. For example, a nurse could scan a number of hospitalizations to see if the patient experienced pressure ulcers in the past or if the patient had a pattern of becoming acutely delirious after receiving anesthesia.

The admission assessment of a prior admission could be referenced so that the nurse does not have to repeat all of the same questions, but simply confirm or add new information.

From Nursing Documentation, in Nursing Malpractice, Fourth Edition

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